Information Governance in Clinical Practice

Information Governance in Clinical Practice: Ethical-Legal Considerations for Nurses

Information Governance in Clinical Practice

Ethical-Legal Considerations for Nurses

Introduction to Information Governance

Information governance refers to the comprehensive framework of policies, procedures, and standards that manage the creation, use, storage, and disposal of healthcare information. It ensures that healthcare information is handled effectively, securely, and in compliance with legal, ethical, and organizational requirements.

In nursing practice, proper information governance is critical for:

  • Maintaining patient privacy and confidentiality
  • Ensuring data quality and integrity
  • Supporting evidence-based practice
  • Facilitating continuity of care
  • Reducing legal and regulatory risks
  • Protecting sensitive health information

The field of healthcare information governance has evolved dramatically with the digital transformation of healthcare systems. Nurses play a pivotal role in this landscape, as they regularly interact with patient data across multiple platforms and systems.

The Four Pillars of Healthcare Information Governance

Compliance & Legal

Adherence to laws, regulations, and standards governing healthcare information

Quality & Integrity

Ensuring accuracy, reliability, and consistency of health information

Security & Privacy

Protection of data from unauthorized access and respecting patient confidentiality

Availability & Use

Ensuring information is accessible to authorized users when needed

Ethical Principles in Healthcare Information

The ethical management of healthcare information extends beyond legal compliance. Ethical information governance in nursing practice is guided by several key principles that align with broader nursing ethics.

Autonomy

Respecting patients’ right to control their information and make informed decisions about its use

Beneficence

Using information to benefit patients and improve health outcomes

Non-maleficence

Preventing harm through information misuse, breaches, or errors

Justice

Ensuring fair distribution of benefits and burdens related to health information

Fidelity

Maintaining trustworthiness in information handling and honoring commitments to patients

Confidentiality

Protecting sensitive information from unauthorized disclosure

Key Ethical Issues in Clinical Information Governance

Privacy vs. Care Coordination

Balancing the need to protect patient privacy with the benefits of information sharing for coordinated care

Consent Management

Ensuring patients understand how their information will be used and obtaining appropriate consent for various uses

Information Access

Determining appropriate levels of access for different healthcare roles while protecting sensitive information

Secondary Use of Data

Ethical considerations around using patient data for research, quality improvement, or commercial purposes

Data Quality and Integrity

Ethical obligation to maintain accurate, complete, and reliable health information

Digital Divide

Addressing inequities in access to digital health technologies and information

Ethics in Digital Healthcare

The digital transformation of healthcare introduces new ethical challenges related to information governance:

Mnemonic: “DIGITAL” Ethics Framework

D – Data ownership and control issues

I – Informed consent in digital environments

G – Governance of algorithm development and use

I – Inclusion and accessibility considerations

T – Transparency in automated decisions

A – Accountability for digital systems

L – Liability in technology-mediated care

Ethical Decision-Making Model for Information Governance

  1. Identify the ethical issue – Recognize when an information governance situation has ethical dimensions
  2. Gather relevant information – Collect facts about the situation, including applicable policies and laws
  3. Consider stakeholder perspectives – Think about impacts on patients, colleagues, and organizations
  4. Identify options – Determine possible courses of action
  5. Apply ethical principles – Evaluate options against core principles
  6. Make a decision – Choose the option that best upholds ethical standards
  7. Implement and evaluate – Act on the decision and assess outcomes

Digital Health Applications in Nursing

Digital health technologies have transformed nursing practice, creating new opportunities and challenges for information governance. Understanding these technologies and their governance implications is essential for contemporary nursing practice.

Telehealth and Remote Monitoring

Telehealth platforms enable remote patient care through virtual visits, remote monitoring, and digital communication. From an information governance perspective, these technologies present unique considerations:

Governance Challenges

  • Ensuring secure transmission of video and audio
  • Managing documentation across physical and virtual encounters
  • Verifying patient identity in remote settings
  • Addressing jurisdictional issues in cross-border care
  • Managing integration with EHR systems

Best Practices for Nurses

  • Use only approved, HIPAA-compliant telehealth platforms
  • Conduct telehealth in private, professional environments
  • Document consent for telehealth services explicitly
  • Follow institutional protocols for remote patient identification
  • Maintain the same documentation standards as in-person care
  • Be aware of state-specific telehealth regulations

Remote Patient Monitoring (RPM) Governance Considerations

RPM devices collect patient data outside clinical settings, creating unique information governance challenges:

  • Device security and data transmission protocols
  • Patient education on proper device use and data handling
  • Alert management and escalation processes
  • Documentation of remotely collected data
  • Data storage and retention policies specific to RPM

EHR Systems and Nursing Documentation

Electronic Health Record (EHR) systems are central to healthcare information governance. Nurses are major users of these systems and must understand their governance implications:

Information Governance Domain Nursing Responsibilities
Data Quality
  • Document accurately and completely
  • Follow standardized terminology
  • Address documentation errors properly
Data Security
  • Maintain password security
  • Log out when not in use
  • Report suspected security incidents
Access Control
  • Access only records necessary for care
  • Understand role-based access limitations
  • Never share access credentials
Copy-Paste Management
  • Use copy-paste functions judiciously
  • Verify copied information for accuracy
  • Follow institutional policies on copy-paste
Record Retention
  • Understand retention requirements
  • Maintain appropriate documentation
  • Know procedures for archive access

Mnemonic: “CHART” for EHR Documentation Governance

C – Clear, concise, and complete documentation

H – HIPAA-compliant practices in all documentation

A – Accurate information that reflects current patient status

R – Relevant content that supports clinical decision-making

T – Timely entry of information according to policy

AI and Decision Support

Artificial intelligence and clinical decision support systems create new information governance challenges in nursing practice:

Governance Challenges

  • Algorithmic transparency and explainability
  • Data quality for AI training and operation
  • Responsibility and accountability for AI-assisted decisions
  • Addressing algorithmic bias and fairness
  • Managing integration of AI outputs into clinical workflows

Nursing Considerations

  • Maintain critical thinking when using AI tools
  • Document rationale for accepting or rejecting AI recommendations
  • Understand the limitations of AI systems
  • Report unexpected or concerning AI outputs
  • Advocate for proper testing and validation of AI used in practice

AI Governance Decision Framework for Nurses

Is the AI system approved for clinical use?

Do I understand its purpose and limitations?

Does the recommendation align with clinical judgment?

Document decision process and rationale

Data Breaches and Security Incidents

Healthcare is increasingly targeted for data breaches due to the high value of health information. Nurses need to understand breach prevention, detection, and response as part of information governance.

Common Healthcare Data Breach Causes

External Threats
  • Phishing attacks
  • Ransomware
  • Hacking
  • Malware
Internal Vulnerabilities
  • Improper access
  • Lost/stolen devices
  • Improper disposal
  • Unauthorized sharing
System Issues
  • Misconfigured settings
  • Unpatched software
  • Weak authentication
  • Poor encryption

Nurse’s Role in Breach Prevention and Response

Prevention Responsibilities
  • Follow secure password practices
  • Recognize and report phishing attempts
  • Secure physical devices and paper records
  • Follow proper screen locking procedures
  • Adhere to information sharing policies
  • Attend security awareness training
Breach Response Actions
  • Immediately report suspected breaches
  • Document incidents according to policy
  • Cooperate with investigation teams
  • Limit additional exposure if possible
  • Preserve evidence when applicable
  • Follow notification processes

Mnemonic: “SECURE” Data Breach Response

S – Stop the breach if possible and secure systems

E – Escalate to appropriate authorities (IT security, compliance)

C – Contain the impact by limiting further access

U – Understand the scope and nature of compromised data

R – Report according to organizational and regulatory requirements

E – Evaluate response and implement preventive measures

Risk Management and Governance Frameworks

Effective information governance requires structured approaches to managing risks. Several frameworks guide healthcare organizations in implementing proper governance structures:

AHIMA Information Governance Framework

Developed by the American Health Information Management Association, focuses on healthcare-specific governance needs.

Key Principles: Accountability, Transparency, Integrity, Protection, Compliance, Availability, Retention, Disposition

NIST Cybersecurity Framework

From the National Institute of Standards and Technology, provides a structure for security governance.

Key Functions: Identify, Protect, Detect, Respond, Recover

COBIT (Control Objectives for Information Technologies)

IT governance framework that can be applied to healthcare information systems.

Key Domains: Plan and Organize, Acquire and Implement, Deliver and Support, Monitor and Evaluate

ISO 27001/27002

International standards for information security management systems.

Key Areas: Security Policy, Organization, Asset Management, Human Resources, Physical Security, Communications, Access Control, Compliance

Risk Assessment Process in Information Governance

1. Identify Assets and Systems

2. Identify Threats and Vulnerabilities

3. Assess Impact and Likelihood

4. Determine Risk Levels

5. Implement Controls

6. Monitor and Review

Nursing Role in Information Governance

Nurses play crucial roles in healthcare information governance at various levels of practice:

Staff Nurse Role

  • Practice proper documentation
  • Maintain data security and privacy
  • Follow information policies and procedures
  • Report security issues and concerns
  • Participate in training and education
  • Advocate for patient information rights

Nurse Leader Role

  • Develop unit-level governance practices
  • Monitor staff compliance with policies
  • Participate in policy development
  • Contribute to system selection processes
  • Lead implementation of information systems
  • Serve as liaison with IT and HIM departments

Informatics Nurse Role

  • Develop governance standards and policies
  • Participate in information system design
  • Evaluate technology impact on workflow
  • Bridge clinical and technical perspectives
  • Lead training and education initiatives
  • Conduct regular governance audits

Nursing Advocacy in Information Governance

Nurses should advocate for:

  • Usable systems that support clinical workflows
  • Inclusion of nursing data in governance frameworks
  • Appropriate nurse representation on governance committees
  • Systems that facilitate rather than hinder nursing care
  • Policies that recognize nursing’s unique documentation needs
  • Training resources specific to nursing information needs

Competencies for Information Governance in Nursing

Core Information Governance Competencies for Nurses

Information Privacy and Security Knowledge

Understanding of privacy laws, security principles, and breach prevention strategies

Documentation Skills

Ability to document accurately, completely, and according to legal and professional standards

Digital Literacy

Proficiency with EHR systems, mobile health apps, and other digital health tools

Ethical Decision-Making

Ability to identify and address ethical issues in information management

Information Evaluation

Skills to assess information quality, relevance, and reliability

Interdisciplinary Collaboration

Ability to work with IT, HIM, compliance, and other departments on governance issues

Case Studies and Practical Applications

Case Study 1: EHR Access Breach

A nurse discovers that a colleague has been accessing the medical records of a celebrity patient who is not under their care. The colleague claims they were “just curious” about the treatment plan.

Governance Issues

  • Unauthorized access to PHI
  • Potential HIPAA Privacy Rule violation
  • Improper use of EHR access privileges
  • Breach of professional ethics

Appropriate Response

  1. Report the unauthorized access to supervisor or privacy officer
  2. Document the incident according to facility policies
  3. Cooperate with any investigation
  4. Maintain confidentiality about the incident

Preventive Measures

  • Regular audit of EHR access logs
  • Refresher training on appropriate record access
  • Clear policies on disciplinary actions for violations
  • Implementation of role-based access controls

Case Study 2: Telehealth Privacy Challenge

A home health nurse is providing telehealth services to a patient when they notice family members in the background who can overhear the conversation, which includes sensitive health information.

Governance Issues

  • Patient privacy in home environment
  • Incidental disclosure of PHI
  • Consent for information sharing
  • Documentation of telehealth privacy challenges

Appropriate Response

  1. Pause discussion of sensitive information
  2. Ask if patient would like to move to a more private location
  3. Confirm patient’s comfort with family members present
  4. Document presence of others during telehealth visit
  5. If necessary, reschedule discussion of sensitive topics

Preventive Measures

  • Pre-visit guidance on setting up private telehealth environment
  • Clear protocols for managing privacy in telehealth
  • Explicit consent process for telehealth services
  • Options for secure messaging for sensitive information

Case Study 3: Social Media Dilemma

A nurse takes a photo of their unit’s team celebrating a successful quality improvement project. Before posting it on social media, they notice that a patient’s information is visible on a computer screen in the background.

Governance Issues

  • Inadvertent disclosure of PHI
  • Social media use in clinical settings
  • Professional boundaries
  • Organizational image and reputation

Appropriate Response

  1. Do not post the photo as is
  2. Either edit to remove/blur PHI or retake the photo
  3. Review organizational social media policies
  4. Consider requesting communication department review before posting

Preventive Measures

  • Clear social media policies for healthcare workers
  • Regular training on digital professionalism
  • Designated photo areas away from PHI
  • Process for reviewing workplace photos before posting

Future Considerations in Information Governance

The landscape of healthcare information governance continues to evolve rapidly. Nurses should be aware of emerging trends and their potential impact on practice:

Blockchain in Healthcare Records

Blockchain technology offers potential for secure, immutable patient records with improved access control.

Governance Implications: New models for record ownership, consent management, and information exchange across organizations.

Patient-Generated Health Data

Increasing integration of data from wearables, health apps, and home monitoring devices.

Governance Implications: New policies for data quality assessment, integration, and shared responsibility for data management.

Advanced AI Clinical Applications

Expansion of AI for diagnostics, treatment planning, and personalized care recommendations.

Governance Implications: Frameworks for algorithmic transparency, validation, responsibility, and ethical use.

Global Health Information Exchange

Cross-border sharing of health information for care continuity and research.

Governance Implications: Harmonization of international regulations, data sovereignty issues, and standardized exchange protocols.

Preparing for Future Governance Challenges

Nurses can prepare for evolving information governance landscape by:

  • Engaging in continuing education on digital health technologies
  • Participating in organizational governance committees
  • Contributing to policy development for new technologies
  • Advocating for nurse involvement in technology selection
  • Developing advanced informatics competencies
  • Monitoring emerging regulatory changes
  • Participating in professional nursing informatics organizations

Additional Resources

Key Organizations and Resources

Professional Organizations

  • American Nursing Informatics Association (ANIA)
  • Healthcare Information and Management Systems Society (HIMSS)
  • American Health Information Management Association (AHIMA)
  • International Medical Informatics Association – Nursing Informatics (IMIA-NI)
  • Alliance for Nursing Informatics (ANI)

Government Resources

  • Office for Civil Rights (OCR) – HIPAA guidance
  • Office of the National Coordinator for Health IT (ONC)
  • National Institute of Standards and Technology (NIST)
  • Centers for Medicare & Medicaid Services (CMS)
  • Federal Trade Commission (FTC) – health privacy resources

Recommended Readings and Tools

Resource Type Recommendations
Books
  • Nursing Informatics and the Foundation of Knowledge
  • Healthcare Information Privacy and Security
  • Legal and Ethical Issues in Health Informatics
  • Information Governance Principles for Healthcare
Journals
  • CIN: Computers, Informatics, Nursing
  • Journal of the American Medical Informatics Association
  • International Journal of Medical Informatics
  • Health Informatics Journal
Online Courses
  • HIPAA Compliance Training
  • Healthcare Information Security Essentials
  • Nursing Informatics Certificate Programs
  • Ethics in Digital Health
Tools
  • HHS Security Risk Assessment Tool
  • AHIMA Information Governance Adoption Model
  • NIST Cybersecurity Framework
  • OCR HIPAA Audit Protocol

Certifications Related to Information Governance

  • Certified in Healthcare Privacy and Security (CHPS)
  • Certified Professional in Health Information and Management Systems (CPHIMS)
  • Certified in Healthcare Privacy (CHP)
  • Certified Information Governance Officer (CIGO)
  • Certified in Risk and Information Systems Control (CRISC)
  • Certified Information Systems Security Professional (CISSP)

© 2025 Nursing Education Resources

These notes are intended for educational purposes only and do not replace professional legal advice.

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